Surgical Procedures

This orthopedic office offers comprehensive fracture care of the upper and lower extremities. The term “fracture” means “break” or implies “broken bone.” There are many types of fractures and the amount of displacement and angulation will dictate treatment. There are threshold measurements for angulation and displacement developed for each fracture of each bone, which provides information on whether to perform casting/immobilization versus operative treatment.

Some fractures that are very displaced or angulated can be treated with a reduction – which means placing it back into a reasonable position, via manipulation. These fractures are subsequently placed into some form of immobilization (ie. – a cast or splint). Reductions of fractures that remain too angulated or displaced usually require surgery for an optimal outcome.

In the gallery, I have provided examples of fractures treated with surgery. There is hardware provided to keep the fractures well aligned.

Arthroscopy

Arthroscopy is minimally invasive surgery, which utilizes a camera and small instruments to treat joint pathology. The camera is magnified 17 times and a video is transmitted to a television screen for optimal viewing. Arthroscopic surgery is utilized to treat many conditions contained in a variety of joints of the upper and lower extremities. Small incisions are made and the joint is insufflated with sterile fluid under pump pressure to aid visualization during the procedure.

Dr. Birnbaum’s training emphasized arthroscopy for treatment of joint pathology. He is adept at perfoming arthroscopy of many joints of the upper and lower extremities. Although he routinely performs shoulder and knee arthroscopy, he has experience in elbow, wrist, and hand/finger joint arthroscopy. He also performs ankle arthroscopy. Below are examples of various joints that are amenable to arthroscopy for diagnosis and treatment of pathologic conditions.

Elbow Arthroscopy

An emerging technique for injuries/conditions concerning the elbow includes elbow arthroscopy. The elbow is a complex hinged joint that is amenable to minimally invasive surgery. Arthroscopy can be utilized for diagnostic purposes that can lead to decision making on whether to perform major open surgery. It is mainly utilized for treatment of elbow joint pathology. The most common indications for surgery include the following: loose body removal, osteophyte (bone spur) excision, debridement of tennis elbow (lateral epicondylitis), synovectomy/debridement arthroplasty to establish better motion, fracture fixation, cartilage replacement (OATS procedure), and diagnostic arthroscopy for collateral ligament injuries.

Just like other joints, elbow arthroscopy is performed with the same principle of making small incisions. These are located on the back part and sides of the elbow. The joint is insufflated with saline solution for improved space and visualization and the camera provides video on the TV screen. This joint probably carries the most risk of nerve injury. There has been extensive anatomic research regarding location of the nerves that cross the elbow joint. This has minimized nerve injury complications. Although nerve injury is rare, it needs to be addressed with each patient prior to performing the procedure. An example of elbow arthroscopy for a tennis elbow case I performed is below.

Knee Arthroscopy

Knee arthroscopy involves performing minimally invasive surgery to correct knee joint pathology. I typically use 2 small 1cm incisions just below the patella. They are located on each side of the patellar tendon. The knee joint is insufflated with sterile fluid via use of a pump which increases the work space by expanding the joint like a balloon. There is a standard long probed camera that is inserted into the outer (lateral) of the incision/portal. The camera is magnified 17 times and the image is projected on a HDTV screen for viewing. The opposite incision/portal is utilized to insert small instruments (biters, shavers, and electrocautery) to take care of the involved pathology. Before and after pictures are taken of the pathology and how it was treated.

The most common indications to perform knee arthroscopy include meniscal tears, focal arthritis, and anterior cruciate ligament tears. There are more indications than the above mentioned, but these are the most common diagnoses eligible for knee arthroscopy. Diffuse arthritis is not considered an indication, but if involved with a meniscal tear, it can be treated (cleaned up) when debriding the meniscus. This depends on the severity of the arthritis. There are a lot of factors involved with whether or not to perform arthroscopy for patients with mild or moderate arthritis. There is no strict rule. The only definitive rule is that severe arthritis is not eligible for arthroscopy. These patients are better served with a joint replacement. Also, patella (knee cap) arthritis usually does not respond to arthroscopic debridement, it is better served with physical therapy.

Shoulder Arthroscopy

Shoulder arthroscopy involves performing minimally invasive surgery to correct abnormal pathology inside or surrounding the shoulder joint. It usually involves three small one centimeter incisions. A standard long probed camera is inserted through the incision in the back (posterior aspect) of the shoulder and the joint is insufflated with sterile saline solution under pump pressure. This will inflate the joint like a balloon that effectively allows more space to work. The camera is 17 times magnified and a projection on a TV screen allows visualization for the surgeon and staff. A second incision is made through the front (anterior aspect) of the shoulder that allows small narrow instruments to enter and take care of the necessary pathology. If there is pathology above the joint, which is above the rotator cuff but below the acromion, a third incision is made on the outer (lateral) aspect of the joint. This area is called the subacromial space. “Before and after” pictures are taken of the pathology and how it was treated. Usually, simple sutures are all that is necessary to close the wounds. More information concerning common shoulder pathology is described below. Multiple x-ray views and an MRI versus MR Arthrogram (injected contrast) are typically performed when surgery is considered an option.

Impingement syndrome is the most common shoulder disorder I see in my office. It usually becomes a problem in patients over 40 years of age. A bone spur on the front (anterior) acromion is the cause. It can be curved or hooked and cause irritation when the shoulder is fully elevated. It is basically an overuse condition and the wear and tear on the rotator cuff and bursa cause pain and breakdown of the tissues. There are a number of common shoulder diagnoses that respond to shoulder arthroscopy. Patients with impingement syndrome and rotator cuff pathology are most commonly eligible to undergo this form of surgery. I usually try to treat impingement syndrome associated with partial thickness rotator cuff tears with a series of cortisone injections and possibly physical therapy as a form of conservative/nonoperative treatment, especially if the shoulder is stiff. If conservative treatment fails, I usually recommend surgery. The procedure is minimally invasive and involves a debridement of the subacromial bursa and shaving the bone spur off of the anterior and lateral acromion. This is known as a “subacromial decompression.” Please see diagram for more details.

Full Thickness Rotator Cuff Tear

In the event of a full thickness rotator cuff tear, I usually recommend surgery as the initial treatment plan. Patients whom are active are eligible for surgery, young or elderly. It is performed similarly as impingement surgery, but in addition, the rotator cuff is repaired back to bone. Suture anchors are utilized and this can be performed with a minimally invasive technique. Small and medium sized tears are amenable to arthroscopic surgery. Massive tears can be more difficult and might require conversion to a mini open procedure (incision around 4 cm in length) versus full open procedure. Please view the arthroscopic pictures for more details. The before and after arthroscopy pictures should tell the whole story. Please note that elderly patients can respond to conservative treatment and surgery is typically not the first option. I provide cortisone injections for pain control. If the shoulder pain persists and is intolerable, I will ultimately offer a surgical repair, if the patient is an appropriate medical risk.

SLAP Tears

A SLAP tear is essentially either shredding or an avulsion of the superior labrum and biceps tendon complex off of the superior aspect (top) of the glenoid (shoulder socket). The biceps tendon becomes confluent with the superior labrum and both attach onto the top of the glenoid (socket of the shoulder joint). This area can be damaged by repetitive overhead activities and/or injury. I generally attempt physical therapy prior to offering surgery. SLAP lesions can be associated with impingement syndrome, so I will utilize cortisone injections on these patients. Should the patient fail conservative treatment, I offer arthroscopic shoulder surgery. The shredded lesions to the superior labrum simply require arthroscopic debridement with a small shaving instrument. The avulsions require an arthroscopic reattachment of the superior labrum/biceps tendon to the glenoid with suture anchors. Results of surgery are more predictable in patients under 50 years of age. Patients older than 50 usually do not require surgery, but there are always exceptions to the rule.

Long Head of the Biceps Fraying/Degeneration

The long head of the biceps attaches on the top part of the glenoid (socket) and superior (top) labrum (see SLAP tears). Sometimes, the biceps tendon can be degenerative without a detached or frayed labrum. Based on the degree of damage to the tendon, a decision will need to be made during surgery via arthroscopy on whether to debride or detach the tendon from its insertion. If there is minimal fraying I will debride the tendon, particularly if the shoulder symptoms are coming from elsewhere. If there is significant tendon fraying, I will divide the tendon via arthroscopy and ultimately perform a small incision to the front of the shoulder and attach the tendon to the groove below the humeral head (ball of joint). This will relieve pain and avoid slippage of the muscle down the arm (Popeye arm). There are 2 attachments of the biceps tendon, one the superior labrum called the long head (located inside the shoulder joint), and another to the coracoid process called the medial head located (located outside the shoulder joint). Although rupture or detachment of the long head of the biceps tendon causes minimal weakness to the arm, it remains a cosmetic deformity and some notice the mild loss in weakness. This is why I prefer to fix the tendon after releasing it.

Acromioclavicular Degenerative Arthritis

The acromioclavicular joint is above the shoulder joint. It attaches the acromion to the clavicle. It is frequently noted to be arthritic and can be painful. It is often associated with impingement syndrome and can be treated conservatively by injecting cortisone into this joint in addition to the subacromial space. If the patient fails conservative treatment, I offer arthroscopic surgery to shave off 1 centimeter of the end of the clavicle. It is known as the arthroscopic “Mumford Procedure.” It reproducibly improves symptoms of pain. Small anterior (front), posterior (back), and lateral (outer) shoulder incisions are needed to perform this procedure. It usually is performed in conjunction with impingement surgery.

Shoulder Dislocations

A shoulder disclocation is most commonly in the anterior/inferior (forward/down) direction. The patient typically goes to the local emergency room to have the shoulder reduced into its native position. The patient should subsequently follow up with an orthopedic surgeon. Treatment after injury is based on the age of the patient. Military studies of patients in their early 20’s have shown that there is a 90% chance of a repeat dislocation. Therefore, arthroscopic shoulder surgery is usually offered as an initial treatment for this age group. Patients older than 30 years of age can be placed in a shoulder immobilizer for 3 weeks and then undergo physical therapy. If the patient dislocates again or feels like the shoulder will with provocative positioning (throwing position), then surgery is offered. The shoulder joint pathology for an anterior dislocation most commonly involves a detached front lower labrum and capsule from the glenoid (socket to shoulder joint). This is called a “Bankart Lesion.” Traditionally, surgery to reattach the capsule and labrum to the glenoid was performed with a large open incision. This can now be reattached more efficiently with arthroscopic shoulder surgery with use of suture anchors. There are conditions associated with dislocations including impaction bony injuries to the humeral head (ball of shoulder joint) or avulsions off the glenoid (socket) that could require more complex surgical procedures. Most unstable shoulders requiring surgery undergo an MR Arthrogram and/or CT scan. The small incisions for the arthroscopic procedure are usually front (anterior) and back (posterior). No outer (lateral) incision is necessary. Patients with loose ligaments to all joints can pose a more difficult problem to treat as well and are sometimes not eligible for an arthroscopic procedure. Rehabilitation is preferred as an initial treatment plan and surgery often performed with an open incision.

Adhesive Capsulitis (Stiff Shoulder)

Adhesive capsulitis is described as stiffness to the shoulder joint. There are a lot of etiologies to this condition, but no matter the source, it is generally treated the same way. It can be associated with any type of shoulder pathology and the symptoms will unfold when motion returns. I usually begin with physical therapy and cortisone injections into the shoulder joint. If the patient fails therapy and cortisone, I will order an MRI to visualize the pathology. The patient is usually eligible for a manual manipulation of the joint under anesthesia (while completely asleep) with or without arthroscopic shoulder surgery. The capsule is noted to be tight and releasing this structure arthroscopically helps loosen the shoulder. Associated pathology includes all of the common shoulder disorders presented on the list that I provided on the previous page. Patients who undergo shoulder surgery for any type of shoulder pathology and sustain adhesive capsulitis postoperatively are sent to physical therapy. If they fail therapy, I usually only need to perform a manupulation under anesthesia – without arthroscopy. Arthroscopy is usually reserved for more severe cases. The amount of capsule to release depends upon which areas are tight and how tight it is.

Shoulder Osteoarthritis

Degenerative osteoarthritis of the shoulder is basically the breakdown of cartilage in the glenohumeral joint (ball and socket joint). The articular cartilage wears out to varying degrees, depending on the progression. Degenerative osteoarthritis is noted to be hereditary (genetic) and can occur spontaneously over time. It can be exacerbated by trauma. It can also present from repetitive wear and tear of usage, usually from manual laborers that perform heavy overhead lifting or repetitive activities with heavy loads.

Treatment always begins with conservative management. Cortisone injections and physical therapy can be helpful, particularly if the shoulder exhibits stiffness. When treatment plateaus, I offer surgery.

Arthroscopy is usually reserved for mild to moderate cases of arthritis. The patient usually has impingement syndrome and/or AC joint arthritis associated with glenohumeral arthritis. The patient can also have a partial versus full thickness rotator cuff tear or a SLAP lesion. Any combination of common shoulder pathology is usually noted and is treated appropriately. Shaving away areas of articular cartilage that are irregular and debriding synovitis is performed in the shoulder joint. Treatment of associated pathology is also performed.

If more severe osteoarthritis is noted prior to surgery, the patient could be eligible for an arthroscopic debridement arthroplasty versus joint replacement. The decision making is usually based on the age of the patient. Younger patients (under 50) are usually offered arthroscopic surgery as a first line of treatment for debridement of cartilage, soft tissue, and bone spurs. Preserving the native joint is a must because of the limited longevity/ultimate failure of prosthetic arthroplasty. Younger patients who fail arthroscopy are offered an arthroplasty, but usually more conservative bone sparing surgery, including debridement with application of biologic tissue coverage of the articular surface of the glenoid (socket of joint) and possibly resurfacing of the humeral head (ball of joint) with a bone sparing metal cap, rather than a full metal prosthesis. Bone grafting procedures for loss of bone stock can be performed as well, if necessary. Patients older than 50 years of age with severe shoulder arthritis can be eligible for less invasive arthroscopic procedures, but might be better served with a total joint replacement.

Combination of Shoulder Pathology

Very commonly, the shoulder exhibits more than one type of pathology that responds to arthroscopic surgery. Most of the list of common shoulder pathology provided on the prior page can occur together. Each type of pathology is treated similarly as if it existed alone. Generally speaking, shoulder instability and stiffness are mutually exclusive (do not occur together), but I have seen cases of Bankart shoulder pathology from prior dislocations associated with shoulder stiffness. This rarely occurs, but if it exists, the procedure to correct each pathologic entity is perfomed as per the specific designated treatment for each disorder. Residual stiffness can be dealt with by offering rehabilitation and possibly a manipulation under anesthesia. There is an important exception in which it is important to not diagnose a young patient with an unstable shoulder with impingement syndrome. Patients under 40 years of age generally do not have impingement syndrome – they have bursitis. They should not undergo a release of the bone spur because this could render them more unstable. The reattachement of the capsule/labrum usually resolves the bursitis, and ultimately the instability.

Ankle Arthroscopy

The ankle joint is amenable to minimally invasive surgery in the form of arthroscopy. Generally, 2 very small incisions are made to the front of the ankle on each side. The joint is insufflated with saline solution to increase space and improve visualization. A camera is inserted into the joint and video is transmitted to a TV screen. There is magnification of the image 17 times for good visualization.

There are few indications to perform ankle arthroscopy, but the pathology is abundant making it a common procedure. Common pathologic conditions/treatments amenable to ankle arthroscopy include: anterior tibial impingement debridement (bone spur), loose body excision, synovectomy (inflamed tissues), cartilage replacement (OATS procedure), and diagnosis of chronic ligament injuries (associated with open repair or reconstruction of ligaments). Below is an example of anterior ankle tibial impingement that was debrided prior to an open lateral ligament repair.

Wrist Arthroscopy

Minimally invasive surgery can be performed on the wrist and can involve arthroscopy. In general, 2 very small 3mm incisions are usually made to the back of the wrist and a small camera is inserted. As with all arthroscopic procedures, fluid is fed into the wrist joint to gain space and improve visualization. There are limited, but common diagnoses that are eligible to undergo arthroscopy. Wrist arthroscopy can be also used for diagnostic purposes that might help a surgeon decide if major open treatment is necessary. The major open procedure can be perfomed at the same setting.

The most common conditions that are amenable to arthroscopy are: scaphoid fracture fixation, scapholunate ligament tears, radial styloidectomy, ganglions cyst excision, ulnar impaction syndrome, and TFCC tears. Although you might not understand the medical terminology, your diagnosis might fit on this list and will allow you to access further information concerning the condition. I have supplied examples of cases amenable to wrist arthroscopy with pictures below.

Joint Replacement

Total joint replacement usually involves prosthetic (metal and plastic) replacement of an arthritic joint. There are biologic tissue replacements as well, but these are uncommon and usually performed in the younger patient who is moderate to severly arthritic. These biologic replacements usually involve the shoulder and elbow joints.

Most moderate to severly arthritic painful and stiff and/or unstable joints are eligible for prosthetic replacement. The ideal age for performing a total joint replacement is greater than 60 years of age. These patients should typically be deemed a low medical risk for surgery by their internist or family physician. Patients under 60 years of age are not excluded, but usually discouraged from undergoing this procedure, unless function and pain is severely limited and attempts at conservative care has failed. Joints that are eligible for total replacement include shoulders, elbows, wrists, fingers, hips, knees, ankles, and toes. Each joint has various protocols for pre and postoperative management.

Out of the list noted above, I perform prosthetic joint replacements on shoulders, elbows, wrists, fingers, and knees. I also perform biological replacement on shoulders and elbows in younger patients who are too young to undergo prosthetic replacement. I have x-ray pictures for review on prosthetic replacements that I have performed on each particular joint in the recent past.

Total Knee Replacement

Total knee replacement is one of the most common prosthetic joint replacements performed. It has a good history of longevity of metal and plastic components that is further improving with newer improved plastic (polyethylene) components. Most last greater than 10 years. It has an excellent track record for relieving arthritic pain and improving function in elderly patients.

The surgical procedure usually involves shaving all arthritic areas of the knee and replacing these areas with metal and plastic components. A certain amount of realignment for bowed legs or knocked knees can also be performed to make the knee straight, which helps with reestablishing normal function.

The general strategy is to try to avoid prosthetic replacement as long as possible. Although a knee replacement is a good procedure, it should be utilized as a last resort because at some point (typically greater than 10 years), it usually requires revision surgery, which is a more difficult and involved procedure and not considered as durable as the first replacement. There are also significant risks (although low) associated with undergoing knee replacement surgery. Nonsteroidal anti-inflammatory medications, cortisone injections, unloader braces, and sometimes arthroscopy can effectively delay surgery. When conservative treatment fails, then I will offer the total knee replacement to the eligible patient.

There is a general consensus that a total knee replacement should be offered to patients over 60 years of age. These patients should be a low medical risk and be able to obtain a medical clearance from their family physician or internist. Sometimes, a subspecialist will need to provide a clearance as well (ie. – cardiologist). The arthritis should be severe and the patient should have failed conservative treatment. The main risks include infection, blood clots (deep venous thrombosis), and postoperative stiffness.

The surgery generally takes 2 hours and the patient is placed on appropriate pain management after surgery. The knee begins motion the next day with a motion machine (CPM) and physical therapy. The patient is encouraged to walk the next day. Antiobiotics are given before and after surgery. A blood thinner is also prescribed. I generally use Lovenox, which is given just under the skin in the lower abdomen daily. Blood counts are performed daily, and if low, a blood transfusion might be necessary. A typical hospital stay is 3 days and the patient will need to make the decision on whether to transfer to a skilled nursing facility or go home with home health care/physical therapy. This usually depends on the activity level of the patient as well as if there is family at home to help with recovery.

The metal and plastic components are cemented into bone, so healing is not necessary of the prosthesis. Soft tissue healing is necessary though and takes around 6 – 12 weeks for a complete recovery. But usually after 2 to 4 weeks, the patient is able to perform most non-strenuous activities. The patient follows up at the office initially at 2 weeks for staple removal, and then monthly for check ups. X-rays are performed to make sure the prosthesis is in good alignment and the knee is checked for wound healing/remodeling and if there is any swelling or infection. Range of motion is also monitored. After 4 months and everything goes as planned, follow up can be at 3 to 6 month intervals.

Please note that the patient needs to be educated on factors that can cause joint infection. A knee infection presents with swelling, redness, increased warmth, and fever. Any dental procedure needs to be addressed with pre procedural oral antibiotics to prevent joint infection. Also, certain bacterial infections to the urinary tract, skin, or lungs could spread from the blood stream to the joint to cause an infection. Antibiotics should be given to address these infections early to prevent the total knee replacement from becoming infected. Contacting your surgeon is a must if an infection is suspected.

An example of a standard type of total knee replacement is shown in the gallery.

Shoulder Arthroplasty

Severe degenerative arthritis of the shoulder can be very debilitating. It usually presents with loss of motion and pain. Treatment is based on the severity of the arthritis and how much function is lost. There are a few treatment options and these depend on how much motion is lost and how much pain is present with functional activities. Loss of motion is usually due to the breakdown of cartilage and associated bone spurs. The patient needs to have an intact rotator cuff or have a rotator cuff that is easily amenable to repair to be eligible for any of the conventional shoulder arthroplasty procedures.

If motion is reasonable, then the pain can be controlled with cortisone injections and possibly physical therapy. If pain persists and motion remains reasonable, then a decision needs to be made on the next treatment plan. Young patients (less than 50 years of age) can benefit from arthroscopy to debride the cartilage and debris/bone spurs. Older patients (greater than 60 years of age) are eligible for arthroscopy, but might be better served with a shoulder replacement.

If motion is limited and pain present, then the younger patient might benefit from biologic patching of the glenoid (shoulder socket) with synthetic tissue or allograft (human donor). If the humeral head (ball of shoulder) is very irregular then a bone sparing metal cap (resurfacing arthroplasty) inserted onto the humeral head with or without synthetic tissue/allograft applied to the glenoid can be performed. Older patients (greater than 60 years of age) that fail conservative treatment with reasonable motion are probably better served with a total shoulder arthroplasty (ball and socket replacement) or hemiarthroplasty (ball replacement – humeral head only). The decision on whether to perform a total replacement versus hemi-replacement is based on the degree of glenoid (socket) arthritis.

If the rotator cuff is significantly torn and arthritis is severe, then a decision needs to be made on whether to perform a rotator cuff repair or tendon transfer with conventional replacement (as above) versus a reverse total shoulder arthroplasty (no need to repair rotator cuff). The reverse total shoulder carries a higher risk of dislocation and fracture as well as other complications. The ball and socket metal components are reversed with and the arm is slightly lengthened to help the deltoid muscle work in place of the rotator cuff. It should be performed sparingly on low demand elderly patients.

This is a general strategy of dealing with shoulder arthritis and there are other options that were not mentioned. The other options are rarely performed, but will always be considered in treatment of this condition.

An example of a standard type of shoulder replacement is shown in the gallery.

Elbow Arthroplasty

Patients with moderate to severe elbow arthritis and lack of functional motion are indicated for an elbow arthroplasty. It is a last resort procedure that is offered when all other attempts of conservative treatment (cortisone injections and physical therapy) and/or surgery fails. It can be performed by recontouring the elbow joint surface and interposing biologic tissue or by use of a prosthesis (metal/plastic) implant. Due the higher complication rate of prosthetic elbow arthroplasty compared to hip and knee arthroplasty, careful scrutiny should be applied to all patients requesting/requiring this procedure.

There are a few less invasive procedures that can be offered with patients with moderate to severe elbow arthritis. One common procedure is a debridement arthroplasty. This can be performed via arthroscopy or an open incision. It can clear out offending bone spurs and release soft tissues that cause stiffness. It probably will not completely cure pain and stiffness, but could allow a reasonable period of time of pain relief and functional motion. Ultimately, it buys time for an elbow arthroplasty. Putting off prosthetic arthroplasty as long as possible is the goal of elbow replacement surgery.

Younger patients (less thanfr 50 years of age) with that meet the criteria of elbow arthroplasty are better served with an interposition elbow arthroplasty. This procedure is well documented in the literature and has good results if performed with an external fixator frame. I wrote a technique paper that outlines this procedure. Essentially, the elbow joint is recontoured after exposing the articular surface and a strip of biologic tissue is placed over the articular surface. It will remodel over the next few months and is hopeful to convert to fibrocartilage. It is a technically demanding procedure and requires healing of ligaments after the procedure. It preserves the natural bone stock and conversion to a prosthetic arthroplasty is easily available, if necessary.

Older patients (greater than 60 years of age) that meet the crtiteria of elbow arthroplasty are better served with prosthetic arthroplasty. It is very important to wait as long as possible prior to offering a prosthetic implant. It can provide pain free and functional motion, but it requires restricted use. There are significant lifting restrictions. There is a 5 pound maximum repetitive and 10 pound maximum single lifting restrictions. They last less than 10 years and failed implants that require revision surgery have much poorer outcomes compared to the initial implant. Multiple revisions and a lack of bone stock will no longer tolerate a prosthetic implant and will result in a flail elbow with no good future solution. Prosthetic elbow arthroplasty is a reasonable procedure when applied judiciously and is readily available for those who meet the appropriate requirements.

Finger Joint Arthroplasty

Patients with severe finger joint arthritis with pain and stiffness are eligible for surgery that could include a prosthetic replacement. There are 3 joints to each finger that include the MCP, PIP, and DIP joints. The MCP joints are at the knuckle and the PIP and DIP joints are the next respective joints from the MCP joints. Conservative treatment includes cortisone injections and hand therapy. If this fails, then surgery is usually the next option. Although stiffness can be improved with arthroplasty, angular deformities of greater than 10 degrees (convergent or divergent) might not be eligible for an implant replacement.

The arthritic MCP joint that meets the requirement for surgery is eligible for a fusion or an implant arthroplasty. The fusion will solve the pain problem, but will not allow motion of this joint. It is offered to the manual laborer who would place more load/torque on the joint. It is also offered to patients with lack of bone stock or significant angular deformity. The goal of an implant arthroplasty is to return the joint to pain free functional motion. There are 2 types of implants that I consider. Pyrocarbon is an excellent material with extremely low wear rates and is offerecd to the younger patient (less than 50 years of age). It has had good mid term results and is my preferred joint replacement. Silicone arthroplasty is offered to older patients (greater than 60 years of age). It is constrained (more stable than the pyrocarbon implants) so it can accommodate poorer bone stock. It is better for the low demand/elderly patient. Its wear rates are too high for the younger patient. Postoperatively, extensive splinting/rehabilitation is necessary for an optimal outcome.

The arthritic PIP joint that meets the requirement for surgery is also eligible for a fusion or joint replacement. The indications for a PIP joint fusion are similar to the MCP joint. This joint is more difficult to perform implant arthroplasty than the MCP joint, so I might be a little more selective on who is eligible for a joint replacement. The implant materials are the same as the MCP, but the pyrocarbon contours are different at the articular surface. Extensive splinting/rehabilitation is necessary for implant arthroplasty because the tendon needs to heal and normal motion is sought.

The DIP joint is that last joint on the finger – near the tip. When arthritic, it can be very debilitating. Conservative treatment includes splinting and cortisone injections. Hand therapy is rarely useful. A fusion of this joint is the only reasonable option. Implant arthroplasty is really not available and not deemed effective. The joint is fused straight or in a touch flexed with K-wires or a small headless compression screw. This is considered an excellent procedure for pain relief and loss of motion to this joint is well tolerated.

An example of a finger PIP Pyrocarbon Arthroplasty is shown in the gallery.

About the Surgeon

Dr. Birnbaum’s academic achievements include being awarded Intern of the Year while at Oakland General Hospital/Michigan State University. He has been directly involved in research and has 2 major publications. His first major publication was completed during his residency. It involves hip screw fixation for children with Slipped Capital Femoral Epiphysis (SCFE). His second major publication was performed during his fellowship at Mount Sinai Medical Center in New York City. It involves interposition arthroplasty of the elbow. The paper supports use of biologic tissue for elbow reconstruction for younger patients with moderate to severe elbow arthritis.